Stipulation With Request For Award {DWC-CA 10214(a)}
STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATION
WORKERS' COMPENSATION APPEALS BOARD
STIPULATIONS WITH REQUEST FOR AWARD | |
| |Date of Injury | |
|Case No. MM/DD/YYYY |
| |
|SSN (Numbers Only) |
|Venue Choice is based upon: (Completion of this section is required) |
|Residence of employee (Labor Code section 5501.5(a)(1)) |
|Location where injury occurred (Labor Code section 5501.5(a)(2)) |
|Principal address of employee’s attorney (Labor Code section 5501.5(a)(3)) |
| |
|Select 3 Letter Office Code For Place/Venue of Hearing (From the Document Cover Sheet) |
|Applicant (Completion of this section is required) |
| | |
|First Name MI |
| |
|Last Name |
| |
|Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Employer #1 Information (Completion of this section is required) |
|Insured Self-Insured Legally Uninsured Uninsured |
| |
|Employer Name (Please leave blank spaces between numbers, names or words) |
| |
|Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator) |
| |
|Insurance Carrier Name (Please leave blank spaces between numbers, names or words) |
| |
|Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Claims Administrator Information (if known and if applicable) |
| |
|Name (Please leave blank spaces between numbers, names or words) |
| |
|Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Employer #2 Information (Completion of this section is required) |
|Insured Self-Insured Legally Uninsured Uninsured |
| |
|Employer Name (Please leave blank spaces between numbers, names or words) |
| |
|Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Insurance Carrier Information |
|(if known and if applicable - include even if carrier is adjusted by claims administrator) |
| |
|Insurance Carrier Name (Please leave blank spaces between numbers, names or words) |
| |
|Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Claims Administrator Information (if known and if applicable) |
| |
|Name (Please leave blank spaces between numbers, names or words) |
| |
|Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Employer #3 Information (Completion of this section is required) |
|Insured Self-Insured Legally Uninsured Uninsured |
| |
|Employer Name (Please leave blank spaces between numbers, names or words) |
| |
|Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Insurance Carrier Information |
|(if known and if applicable - include even if carrier is adjusted by claims administrator) |
| |
|Insurance Carrier Name (Please leave blank spaces between numbers, names or words) |
| |
|Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Claims Administrator Information (if known and if applicable) |
| |
|Name (Please leave blank spaces between numbers, names or words) |
| |
|Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Employer #4 Information (Completion of this section is required) |
|Insured Self-Insured Legally Uninsured Uninsured |
| |
|Employer Name (Please leave blank spaces between numbers, names or words) |
| |
|Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Insurance Carrier Information |
|(if known and if applicable - include even if carrier is adjusted by claims administrator) |
| |
|Insurance Carrier Name (Please leave blank spaces between numbers, names or words) |
| |
|Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Claims Administrator Information (if known and if applicable) |
| |
|Name (Please leave blank spaces between numbers, names or words) |
| |
|Street Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|The parties hereto stipulate to the issuance of an Award and/or Order, based upon the following facts, and waive the requirements of Labor Code section 5313: |
|1. | |
|Employees First Name |
| |
|Employees Last Name |
|birth date | |
|MM/DD/YYYY |
|while employed at | |, | |
|State |
|as a(n) | |, | |in |
|Occupation Group |
| More than 4 Companion Cases |
|Specific Injury |
| | | |
|Case Number 1 Cumulative Injury |(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) |
| |(If Specific Injury, use the start date as the specific date of injury) |
|Body Part 1: | |Body Part 2: | |Body Part 3: | |
|Body Part 4: | |Other Body Parts: | |
| Specific Injury |
| | | |
|Case Number 2 Cumulative Injury |(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) |
| |(If Specific Injury, use the start date as the specific date of injury) |
|Body Part 1: | |Body Part 2: | |Body Part 3: | |
|Body Part 4: | |Other Body Parts: | |
| Specific Injury |
| | | |
|Case Number 3 Cumulative Injury |(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) |
| |(If Specific Injury, use the start date as the specific date of injury) |
|Body Part 1: | |Body Part 2: | |Body Part 3: | |
|Body Part 4: | |Other Body Parts: | |
| Specific Injury |
| | | |
|Case Number 4 Cumulative Injury |(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) |
| |(If Specific Injury, use the start date as the specific date of injury) |
|Body Part 1: | |Body Part 2: | |Body Part 3: | |
|Body Part 4: | |Other Body Parts: | |
|by the employer(s) and their insurer(s) listed above and who sustained injury(ies) arising out of and in the course of employment to |
| | |
|(Please list all body parts injured) | |
|2. The injury (ies) caused temporary disability for the period | |through |
|MM/DD/YYYY |
| |for which indemnity has been paid at $ | |per week. |
|MM/DD/YYYY Indemnity Paid |
|2(a).The injury(ies) caused additional temporary disability for the period | |
|MM/DD/YYYY |
|through | |at the rate of $ | |in the amount of $ | |
|MM/DD/YYYY Rate Indemnity Paid |
|3. The injury(ies) caused permanent disability of | |% for which indemnity has been paid at $ | |
|Indemnity Paid |
|per week beginning | |in the sum of $ | |, less credit for such payments |
|MM/DD/YYYY |
|previously made. And a life pension of $ | |per week thereafter. |
|Life Pension |
|Labor Code §4658(d) adjustment: |
| Increase rate to $ | |as of | |
|MM/DD/YYYY |
| Decrease rate to $ | |as of | |
|MM/DD/YYYY |
|Not Applicable |
|An informal rating has / has not (Select one) been previously issued in case no(s) | |.|
|4.There is is Not a need for medical treatment to cure or relieve from the effects of said injury (ies). |
|5. Medical-legal expenses and/or liens are payable by defendant as follows: |
| | | |
| | |
|6. Applicant's attorney requests a fee of $ | |
| Fees to be commuted as follows: |
| | |
|7. Liens Against compensation are payable as follows: |
| | |
|8.Any accrued claims for Labor Code section 5814 penalties are included in this settlement unless expressly excluded. |
|9.Other stipulations: |
| |
|Dated | | |
|MM/DD/YYYY |Applicant |
| | |
|Applicant's Attorney or Authorized Representative: |
|Law Firm/Attorney Non Attorney Representative |
| |
|First Name |
| |
|Last Name |
| |
|Firm Number |
| |
|Law Firm name |
| |
|Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Dated | | |
|MM/DD/YYYY Applicant Attorney Signature |
|Defendant's Attorney or Authorized Representative: |
|Law Firm/Attorney Non Attorney Representative |
| |
|First Name |
| |
|Last Name |
| |
|Firm Number |
| |
|Law Firm Name |
| |
|Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Dated | | |
|MM/DD/YYYY Defense Attorney Signature |
|Defendant's Attorney or Authorized Representative: |
|Law Firm/Attorney Non Attorney Representative |
| |
|First Name |
| |
|Last Name |
| |
|Firm Number |
| |
|Law Firm Name |
| |
|Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Dated | |
|MM/DD/YYYY | |
|Defense Attorney Signature |
| |
|Defendant's Attorney or Authorized Representative: |
|Law Firm/Attorney Non Attorney Representative |
| |
|First Name |
| |
|Last Name |
| |
|Firm Number |
| |
|Law Firm Name |
| |
|Address/PO Box (Please leave blank spaces between numbers, names or words) |
| | | |
|City State Zip Code |
|Dated | | |
|MM/DD/YYYY Defense Attorney Signature |
| |
|Interpreter Licence Number: |
| | |
|Interpreter Name Interpreter License Number |
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